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Truckers Insurance Quote Form

                 Applicant:    
              Company name:     
                   Address:    
                 Your City:    
                Your State:    
             Your ZIP code:    
          Telephone Number:    
           Your Cell phone:    
           Your Fax Number:    
       Your e-mail address:    
                ICC Number:    
                DOT Number:    
           Type of carrier:

Type of cargo hauled:
(Please list by percentage of load if more than one type of cargo carried)
	Avg. value	Load Max. value	Load % of total loads
Machinery
Tobacco
Produce
Chilled Food
Frozen Food
Building Materials
Automobiles
Other

Is reefer coverage required?   Yes No

Gross receipts last 5 years:   



Please give details of the number of vehicles for which cargo
coverage is required:

Tractor Units		Reefer trailers 10 yrs old or less
Straight Trucks		Reefer trailers more than 10 yrs old
Reefer trucks		Flat bed trailers
Tank trucks		Tank trailers
Other power units		Other trailers
--------------- ---------------
Total power units		Total trailers

Percentage of hauls by distance:
1-250
251-1000 miles
1001+miles

Total number of drivers:      
# drivers under 25 yrs. old:  
# drivers over 60 yrs. old:   
Current insurance carrier:    
          List any losses:

claims last 3 years: Check here if none

Please provide us with as much detailed information about your
Trucks, Commercial Auto, and Driver List Information or submit form and FAX detailed info to: 201-291-1702.

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